HETEROGENOUS EFFECTS OF MEDICARE BENEFIT FOR ADVANCE CARE PLANNING CONVERSATION BY SOCIODEMOGRAPHIC FACTORS

Abstract Background Although Medicare makes the option of physician-patient advance care planning (ACP) discussion available to everyone starting in 2016, older adults from disadvantaged backgrounds may be less likely to benefit from the policy. Motivated by Fundamental Cause Theory, this study examines the heterogenous policy effect, as a natural experiment, on older adults’ ACP uptake. Methods Data were from Health and Retirement Study 2012-2020 with 15,647 individuals. I used two quasi-experimental models – interrupted time series (ITS) analysis and difference-in-difference (DID) – to study ACP outcomes before and after the policy implementation between older adults who were Medicare-eligible and those who weren’t. I studied the heterogenous effects in stratified samples by race/ethnicity, immigration background, and socioeconomic status. I used coarsened exact matching to address the potential bias that the comparison group is not the ideal counterfactual control unit. Results DID reveals that, in the total population, Medicare expansion was associated with a significant increase (0.05 percentage point) in the proportion of older adults who completed advance directives, but not for having informal conversations. Furthermore, I find no evidence that the Medicare expansion was effective in improving the rates of ACP among Black, Hispanic, Asian or Native American, or non-US-born older adults. Lastly, based on ITS results, the policy only has significant immediate policy effects (level change) on ACP uptake, but not for sustained effects (slope change). Discussions: The current policy reproduced the disparities in ACP. I discuss health policy recommendations to improve the ACP rate among older adults with disadvantaged backgrounds.


CLINICIAN EXPRESSIONS OF CONDOLENCE AFTER THE DEATH OF A PATIENT: AN INTERNATIONAL SURVEY
Katlynn Van Ogtrop 1 , Sofie Nelson 2 , Christian Nouryan 1 , Kevin Carratu 3 , and Maria Carney, MD 1 , 1. Northwell  Health, Manhasset, New York, United States, 2. Northwell  Health Physician Partners Geriatrics and Palliative  Medicine at New Hyde Park, New Hyde Park, New York,  United States, 3. Feinstein

Institute for Medical Research, Manhasset, New York, United States
There is little literature about expressions of condolence from providers to family members of those that have died, and no known literature reported during the COVID-19 pandemic.This study utilized an investigator-developed survey of healthcare clinicians about contacting families of patients who have died.It conducted via email and online from October to December 2021.Of 131 respondents, 67% were female, from 23 states, Canada, and UK.Half (49%) had >15 years experience, and most (85%) were attending physicians.The majority (99%) reported that a patient had died in their care within last year, while 18% reported lost >10 patients per month.Methods of condolences were phone calls, and personal letters.Most (67%) reported no change in contacting families, while 23% increased.When asked if they would be interested in education on expressing condolences, 47% responded "yes."Barriers to condolences were time (64%), unsure of what to say (20%), afraid family will be upset (19%), medical/legal reasons (10%), no training (8%), and no personal relationship (7%).Most, (85%) reported that most calls "went well or better than expected."Females (vs.male) reported often/always sending letters (45% vs 20%, p=0.13), and often/always calling by phone significantly more (71% vs 63%, p=0.04).Younger (< 40) clinicians (vs.older) reported being very/moderately comfortable talking to families (72% vs 78%, p=0.79), phone calls (64% vs 69%, p=0.68) and personal letters (27% vs 42%, p=0.91).Nearly half of respondents requested training.This is a practice that should be further studied for clinician and family experience purposes.

HETEROGENOUS EFFECTS OF MEDICARE BENEFIT FOR ADVANCE CARE PLANNING CONVERSATION BY SOCIODEMOGRAPHIC FACTORS Yifan Lou, Yale University, New Haven, Connecticut, United States
Background: Although Medicare makes the option of physician-patient advance care planning (ACP) discussion available to everyone starting in 2016, older adults from disadvantaged backgrounds may be less likely to benefit from the policy.Motivated by Fundamental Cause Theory, this study examines the heterogenous policy effect, as a natural experiment, on older adults' ACP uptake.Methods: Data were from Health and Retirement Study 2012-2020 with 15,647 individuals.I used two quasi-experimental models -interrupted time series (ITS) analysis and difference-in-difference (DID) -to study ACP outcomes before and after the policy implementation between older adults who were Medicareeligible and those who weren't.I studied the heterogenous effects in stratified samples by race/ethnicity, immigration background, and socioeconomic status.I used coarsened exact matching to address the potential bias that the comparison group is not the ideal counterfactual control unit.Results: DID reveals that, in the total population, Medicare expansion was associated with a significant increase (0.05 percentage point) in the proportion of older adults who completed advance directives, but not for having informal conversations.Furthermore, I find no evidence that the Medicare expansion was effective in improving the rates of ACP among Black, Hispanic, Asian or Native American, or non-US-born older adults.Lastly, based on ITS results, the policy only has significant immediate policy effects (level change) on ACP uptake, but not for sustained effects (slope change).Discussions: The current policy reproduced the disparities in ACP.I discuss health policy recommendations to improve the ACP rate among older adults with disadvantaged backgrounds.
Abstract citation ID: igad104.2367Supporting care transitions as decline occurs for patients facing serious illness and their families necessitates ongoing identification of person-centered, family-oriented goals.However, little is known about the process patients and caregivers undergo when making decisions while transitioning to home hospice care.Using a Straussian grounded theory approach, we explored processes patients and caregivers use when transitioning from cure-to comfortfocused care.Data were collected through eight interviews of patients, patient and caregiver dyads, and hospice nurses (n=11).Participants were recruited from hospice and palliative care agencies serving three counties in Western New York.Interviews were recorded and transcribed verbatim.Data were analyzed using constant comparative method.Our results generated a theory grounded in the process of maintaining personhood and autonomy (e.g., changing roles, losing sense of self, wanting to be heard, wanting privacy) while making decisions to transition to hospice care.This process includes five contemporaneous steps: Shopping for the right services (e.g., recognizing existing care limitations, overcoming systemic barriers), Involving caregivers (e.g., acting as an advocate, filling other family members in, accepting the patient's decisions), Navigating the business of dying while living (e.g., dealing with legalities, planning for the end), Processing and expressing emotions (e.g., fear, anger, trauma, loss), and Seeking input as health declines/recognizing futility (e.g., pursuing a diagnosis, validating what is happening with the nurse and physician, recognizing options).The process identified in the study reveals important mechanistic targets for the development of interventions that promote patient-centered hospice care transitions in the home setting.Background: Many studies have focused on the association between individual-level factors and end-of-life care.Yet neighborhood-level factors and end-of-life care are understudied and thus remain unclear.This study aims to examine the association between neighborhood characteristics and U.S. older adults' end-of-life care to fulfill the existing research gaps.Method: Data were from the 2008 to 2016 Health and Retirement Study exit interview (n = 1,561) who answered left behind questionnaires.Participants included community-dwelling adults aged 55 years or older who died between waves.End-of-life care is measured from three dimensions: health service utilization, quality of life, and advance care planning; Neighborhood characteristics include neighborhood cohesion, which was assessed with 4 items to measure the extent to which respondents feel about the neighborhoods and neighbors' trust; neighborhood physical disadvantage, which was assessed with 4 items to measure the extent to which respondents feel about the neighborhoods' physical problems.Logistic regressions with sociodemographic and health controls were conducted.

MAINTAINING PERSONHOOD AND AUTONOMY: A GROUNDED THEORY OF COMMUNITY-BASED HOSPICE CARE TRANSITIONS
Results: A higher level of perceived neighborhood cohesion and lower level of perceived neighborhood physical disadvantages are significantly associated with a lower likelihood of being admitted to the ICU, getting life support, and having trouble with pain.Higher neighborhood cohesion is also associated with increased odds of having a living will (OR= 1.10, p < 0.05).Neighborhood characteristics are not associated with end-of-life hospitalization, use of hospice, depres-